Any person who sells, gives, delivers or otherwise disposes of 20 pounds or less of smokeless powder, or one pound or less of black sporting powder, shall first obtain a statement from the person who purchases or otherwise receives such powder, which statement shall include:

1. (a) The name, address and birth date of the person purchasing or receiving the powder.
2. (b) The purpose for which the powder is intended to be used, handled, stored, or possessed.
3. (c) The type and amount of the powder.
4. (d) The signature of the person purchasing or receiving the powder.

5. (e) The driver’s license number, selective service card number, or other identifying information concerning the person purchasing or receiving the powder.

   Any person furnishing a fictitious name or address or knowingly furnishing an incorrect birth date and any person violating any of the provisions of this section is guilty of a misdemeanor.